Healthcare Provider Details

I. General information

NPI: 1467518639
Provider Name (Legal Business Name): ETHEL LEE ROBERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3942 BITTER SPRINGS DR
FORT IRWIN CA
92310-1597
US

IV. Provider business mailing address

4TH AND INNER LOOP
FORT IRWIN CA
92310-1597
US

V. Phone/Fax

Practice location:
  • Phone: 760-900-2338
  • Fax:
Mailing address:
  • Phone: 760-380-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number224780
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: